SMA-SNA CPR TRAINING PROGRAMME

REGISTRATION FORM

FULL NAME: DR / MR / MS / MRS _________________________________________

NRIC/ FIN NO. _____________________ MCR NO. _________ AGE: _________

PROFESSION: _________________________________GENDER: MALE / FEMALE

MAILING ADDRESS: ____________________________________________________

_______________________________________________POST CODE: ___________

PRACTICE ADDRESS: ___________________________________________________

_______________________________________________ POST CODE: ___________

CONTACT: _________________ (OFC) ______________ ______ (HANDPHONE)

EMAIL: __________ ______________________

BCLS CERTIFICATE ISSUED BY: ____________ ____ EXPIRY DATE: __________

Membership Status: SMA Non Member

(please tick whichever is applicable)

Please register me for the BCLS BCLS Recert BCLS Recert + AED
(please tick whichever is applicable) AED
Day /Choose Date: Sunday 20May18, 24June18, 15July18, 19Aug18
Course Fees per participant (GST Inclusive):

Type of course SMA Member Non Member

AED $80.25 $128.40
BCLS Recert + AED $149.80 $256.80
BCLS Re-cert $80.25 $128.40
BCLS $128.40 $214.00
Policy for NO refund:

* Absent without notification (no show) or less than 1 week’s notice - no refund

Payment: Cash / Cheque

I enclose my cheque No. ______________ for $ _______________ made payable
to “Singapore Medical Association Pte Ltd”. [Cheque to be mailed to SMA Pte Ltd, 2
College Road, Level 2 Alumni Medical Centre, Singapore 169850.]

Date: ________________ Signature: ______________________

Cpr.Regfm.December 2017